One of the greatest medical sermon of our times is “Doctors must constantly update their knowledge , Continuing medical education is as sacred as their profession ! If you are not updating your knowledge you cease to a doctor “

It is fashionable , but true to state modern medicine lacks humane care . Modern medicine is challenged by a huge technological , commercial onslaught where common sense takes the back seat

Hence , doctors need to renew not only their academic competence but also their ethical fitness every year !

Aggression could be the other name for modern medical care . For every new invention , treatment or guideline that is approved an equal number is shelved after few months or years for safety reasons.

Bulk of medical updates for current age physicians is nothing , but asking them to forget all those wrong things that has been meticulously uploaded in their brains in the recent past ( Recall the classical story of drug eluting stents )

If this is the case . . . then . . . what for we are updating ? and for what we are learning and forgetting ? and . . . how frequent we need to forget ? Of course , there is a big chunk of human tribe who can never master the art of forgetting ! Some mistakes are permanently etched in their terra byte hard disks .

Is there a place for backdating and discontinuing medical education ?

What man- kind needs at times of medical crisis , is not the current treatment but the correct treatment .It is our duty to find all those trustworthy drugs & treatment modalities that were sent to the gallows by the modern medical forces for various reasons !

If some of the gems in medicine are left behind in past “time domain” , it is mandatory for us to go back in time and catch it , adopt it and disseminate it !

Further , whenever the hyped “medical updating sessions ” turns out to be synonymous with adding nonsense (It is becoming all too common these days !) we should resist it by all means !

For many . . . Hippocrates and his medicine sounds dirty now !

If only we back-date our knowledge . . .

Todays youngsters can learn a secret that liver enlargement can be diagnosed easily with their hands , without waiting for a CT scan report !

If only we back-date our knowledge . . .

We can realise Aminophylline can save so many lives of cardiac failure , which our newer inotropic agents are struggling to accomplish .

If only we back- date our knowledge . . .

We can calmly manage acute MI with lignocaine even in a country side . Amiodarone unfairly replaced this efficient anti VT molecule for no academic reasons !

If only we back- date our knowledge . . .

We can advice simple non pharmacological intervention for stage 1 HT than prescribing the glamorous sartan molecules form a multinational ARB shoppe.

If only we back- date our knowledge . . .

We can promptly recognise cardiac failure without ordering for the error prone BNP . Back dating also helps us to under stand that post infarct angina is a glaring sign for presence of viable myocardium and prevent us from undertaking a 2000 $ PET excursion !

If only we back- date our knowledge . . .

We can send all our uncomplicated , asymptomatic STEMI patients ( in class 1 ) straight to their home rather than to cath lab play grounds !

This article is in response to the prevalent belief about primary PCI for STEMI endorsed by world cardiology forums. (Caution: A highly personalized version)

Time window in STEMI

Is the window half-opened or half closed ?

Is it open at all ?

Or ,does it open only for primary PCI ,and tend to close down bluntly for thrombolysis

Modern medicine grew faster than our thoughts .We have witnessed the audacity of advising arm-chair treatment for MI till later half of last century . Now we are talking about air dropping of patients over the cath lab roofs for primary PCI.

Still ,we have not conquered the STEMI. While , we have learnt to “defy death” in many patients with cardiogenic shock , we continue to lose patients(“Invite death “) in some innocuous forms of ACS due to procedural complications and inappropriate ( rather ignorant !) case selection.

Note : The ignorance is not in individual physician mind , it is prevalent in the whole cardiology knowledge pool.

The crux of the issue for modern medicine is , how to reduce risk in patients who are at high risk and how not to convert a low risk patient into a high risk patient by the frightening medical gadgets.

In other words , arm chair treatment for STEMI was not (Still it is not !) a dustbin management . It has a potential to save 70 lives out of 100. What many would consider it as , nothing but the natural history of MI .

Medical management of STEMI is ridiculous !

That’s what a section of cardiologists try to project by distorting the already flawed evidence base in cardiology. Some think it is equal to no treatment. Here we fail to realise, even doing none has potential to save 70 lifes out of 100 in STEMI who reach the hospital.

Out of the remaining , 10 lives are saved by aspirin heparin (ISIS 2) and the concept of coronary care . Another 7 lives are saved by thrombolysis (GUSTO,GISSI) . PCI is shown to save saves one more life (PAMI).The remaining 6-7 % will die in CCU irrespective of what we do .

Of course , now medical management has vastly improved since those days . A thrombolysed , heparinsed , aspirinised , stanised with adequately antagonized adrenergic , angiotensin system and a proper coronary care ( That takes care electrical short-circuiting of heart) will score over interventional approach in vast majority of STEMI patients.

Now comes the real challenge . . .

When those 70 patients who are likely to survive , “even a arm-chair treatment“, and the 20 other patients who will do a wonderful recovery with CCU care , enter the cath lab some times in wee hours of morning . . .what happens ?

What are the chances of a patient who would otherwise be saved by an arm-chair treatment be killed by vagaries of cath lab violence ?(With due apologies ,statistics reveal for every competent cath-lab there are at least 10 incompetent ones world over !)

In the parlance of criminology , a hard core criminal may escape from legal or illegal shoot out but an innocent should not die in cross fire , similarly , a cardiogenic shock patient with recurrent VF is afford to lose his life , but it is a major medical crime to lose a simple branch vessel STEMI (PDA,OM,RCA ) to die in the cath lab, whom in all probability would have survived the arm chair treatment.

Why this pessimistic view against primary PCI ?

Yes, because it has potential to save many lives !

Time and again , we have witnessed lose of many lifes in many popular hospitals in India , where a low risk MI was immediately converted to a high risk MI after an primary PCI with number of complications .

I strongly believe I have saved 100s of patients with low risk MIs by not doing for primary PCI in the last two decades.

*The argument that PCI confers better LV function and longterm beneficial effect is also not very convincing for low risk MIs .This will be addressed separately

The demise of comparative efficacy research.

Primary PCI is superior to thrombolysis : It is agreed , it may be fact in academic sense .

Why we have not developed a risk based model when formulating guidelines for primary PCI ?

Is primary PCI for a PDA /D1/OM infarct worth same as PCI for left main ?

Is high volume center guarantee best outcomes ?

Who is preventing comparative efficacy studies ?

Primary PCI : Still struggling !

This study from the archives of internal medicine tells us , we are still scratching the tips of iceberg (Iceberg ? or Is it something else ?) of primary PCI

Even a pessimistic approach can be more scientific than a optimistic !

When WHO can be influenzed and make a pseudo emergency pandemic and pharma companies make a quick 10 billion bucks , Realise how easy it is for the smaller , mainstream cardiology literature to be hijacked and contaminated .

Final message

Why we reverently follow the time window for thrombolysis, while we rarely apply it for PCI ? This is triumph of glamor over truth . The open artery hypothesis remains in a hypothetical state with no solid proof for over 2o years since it was proposed.

Apply your mind in every patient , do a conscious decision to either thrombolyse , PCI or none . All the three are equally powerful approaches in tackling a STEMI , depending upon the time they present .Remember , the third modality of therapy comes free of cost !

Never think , just because some one has an access to a sophisticated cath lab 24/7 , has a iberty to overlook the concept of time window !

Probably, the best journal that is going to have the greatest impact in cardiology practice in the future could be this . . .

Unfortunately most cardiologists are unaware of this journal . The need for this journal , that too from most respected Circulation family , will vouch for its importance in the current era of cardiology that is driven more by the market forces than by the academics.

This journal is 3 year old , and most of the medical colleges do not subscribe to this.

None of the 100 cardiologists who were questioned , were unaware of such a journal.

Even those who read this journal often term as boring , academic and not practical !

The Circulation team which started this journal with only one purpose . . .that is , auditing the uncontrolled proliferation of pseudoscientific literature without proper quality assessment and dubious outcomes. Three cheers to the circualtion team for publishing this journal and let us propogate the importance of this publication.

When we get contaminated with excess knowledge , we lose our ability to think ! & Common sense is the casuality . . .

Human beings differ from other forms of life by their sixth sense . Our planet is few billion years old . Life came into existence over a million years ago .Our life has evolved over many thousands of years .The average life span of human race is 75 years . We need to realise , our life constitutes only a fraction of our planet’s life (<.0000001% ) . A may fly , which lives a life of less than a day , does it in style , looking for the light throughout the night , says good bye , to earth by morning leaving it unharmed . Actually , in terms of time , the life of the fly is just a fraction less than human life span , when compared to our planet’s life !

When these children are longing for food , some of earthly humans go to spend millions for obesity surgery ! That is the progress of knowledge driven society . . .

It is extremely common to experience the following scenario in any corporate hospitals of both developing and developed country .A uninsured or half insured ! person is refused entry into a hospital even for an emergency care while a wealthy person is lying comfortably watching TV in a five star suit of the same hospital after an inappropriate coronary angioplasty for an innocuous lesion of his heart !

The irony is , in this short span of earthly life , we want to prevail over the nature and conquer the planet . God is watching this human behavior silently . And he is smiling . . .

With all our knowledge base , modern science have done the maximum possible damage to our planet .We have made many lives extinct. If we tend to think , with the help of 6th sense we can become immortal , it would be the ultimate foolishness. When every one of us , is obsessed with our own health , we are deaf to the silent cries of our beloved planet earth .

Now , all of a sudden we realise all the accumulated knowledge & development has actually worked against us. We find our knowledge is dissociating our thoughts and now , we are fighting vigorously over acquiring the rights to damage our planet .

So it seems , the more we learn, less wisdom we have ! We may need to learn important lessons of living from all those species which do not boast to have the 6th sense !

Read a related article , excellent one published in British medical journal nearly 2 decades ago

Pessimism, from the Latin pessimus (worst), is a state of mind which negatively colors the perception of life, especially with regard to future events.

Understanding pessimism is not that simple . Some people argue optimism represents a strong mind while a pessimism is the domain of the weak . But it is not necessarily true. Both pessimist and optimist are unreal , and playing the dangerous game of predicting the future. So realism is the answer .

In this era of information highways , commercial exploitation of science , our thought process is grossly determined by our perception of events.We hardly have an intention or time to analyse our thought process.

An optimist ( Rather , unregulated optimist ! ) is a person who welcomes any growth good or bad.*

A pessimist is a person who welcomes only good growth.*

So how to identify good growth ? That is the million dollar question!

Many of the optimists may not bother about the final outcome of a treatment *

A pessimist bothers only about that .

An optimist rarely asks questions, blindly accepts every thing !

A pessimist never believes any thing !

Actually the fundamental principle of scientific medicine lies in proving the null hypothesis null and void.Any treatment is useless until proved other wise . So pessimist can be argued to follow true science , while many of the hardcore optimists are blind believers ..

*It may be a harsh way of interpreting an optimist but uncontrolled optimism has played havoc in our patients like many of the failed treatments (Some of them released prematurely into patient domain has killed many lives . Power of positive thinking should be within the realms of scientific feasibility !

So in our journey to conquer human health , we may proceed with an optimistic mind and a pessimistic eyes !

This understanding is all the more important in this era of contaminated science .It is a well known fact , now last 50 years of planet earth has inflicted the maximum damage to ourselves than our ancestors did in 5000 years. That’s why we are compelled to meet at Copenhagen .(We never learn from our mistakes, that’s a different story !) .

There is definite and urgent need for world summit on cleansing the medical science from the clutches of commerce and ignorance . A medical green house effect, with dangerous holes in health care is imposing on us (Another pessimistic thought . . . of course in the interest of human kind !)

World health organization , a sleeping giant has to be awakened on this issue

Final message:

Mankind has evolved over many millenniums , probably with a sole purpose of living , that is reproduction and propagation of our genre without harming the environment and other species.

Unrestricted and unregulated growth of any kind is dangerous we call it as malignancy in pathology .In science , we tend to call it a” great future ”

Our sixth sense* has outgrown miserably out of reality , as have we decided to take on the nature and GOD .Now , many developing country men do not believe in death .They are fighting a losing battle against the God. And they suffer with escalating health costs of keeping the elderly , alive who are knocking at the doors of heaven or hell . The same countries, which deny funds for curable illnesses of the poor is a different story altogether !

The principle of modern medicine would ideally be

Reduce human suffering irrespective of economic status

Curing a illness if there is a cure

Prolonging life if there is useful purpose

Allow a good quality death if there is no cure.

Most importantly , prey to god give us strength and capacity to identify which is good and which is bad for our patients .

Read and learn for a complete guide on optimism and pessimism

* It is important to recognise , the same sixth sense has made it possible to share our views through a great tool of Internet . So we should not be against the growth of science but against the misuses and wrong interpretations of it .

The fact that observational studies are done with open eyes & mind , it is obvious it demands intense conceptualization and thinking .
Blinded studies are mechanical studies . It is pure statistical research . It requires no thinking , medical mind , in fact one can do it with eyes closed as it is a strict protocol driven , even a non medical men can do a medical research , while it needs a alert mind to do a observational study .

Observational studies , especialy when done retrospectively has zero bias as the case selection and the potential intervention are completed even before the research question is raised. In fact many of the greatest medical breakthrough comes from retrospective analysis. Of course this has to be proved prospectively preferably in a randomised fashion.

So , we the medical professionals , shall do great observational research with open eyes and mind and let the the statisiticins do the outcome analysis blind folded .

If the core medical professionals are bothered more about randomised blinded studies ,which is meant only for evaluation purposes , the future of intellectual medical research is going to be in jeopardy!